Lessons from the Inquiry into the King Edward Memorial Hospital Obstetrics

and Gynaecological Services

Presentation to

Womens Hospitals Australasia/Childrens Hospitals Australasia

National Conference, Perth, 10 April 2001

by

Dr Michael Walsh,

Deputy Chair, Australian Council for Safety and Quality in Health Care

Why is ACS&QHC Why is ACS&QHC Interested?Interested?

• Make the findings of the Inquiry more accessible and relevant

• Identify lessons and opportunities for system change

• Identify lessons and opportunities for operational management and governance change

• Work cooperatively with stakeholders (KEMH, HDWA, WHA/CHA)

Overview of DiscussionOverview of Discussion

• Review of Inquiry and Findings

• Lessons for Health Care Institutions: operational/clinical management governance

• Lessons for System and Policy-makers

King Edward ProfileKing Edward Profile

• WA’s only tertiary referral services for obstetrics and gynaecology

• 250 inpatient beds, neonatal intensive care, outpatients and specialist emergency services

• 5,000 births per year

• 5,000 gynaecology operations

• 8,000-10,000 emergency presentations

• High and increasing case complexity

Lead-up to InquiryLead-up to Inquiry

Significant change and upheaval including:

• merger with children’s hospital

• two new chief executives; devolved management

• focus of MHSB taskforce to review WA O&G

• steering group reviewed recommendations

• independent review by retired clinician

• Child and Glover review

• strong public debate about future of KEMH

Inquiry’s BriefInquiry’s Brief

• Established under Hospitals and Health Services Act

• Examine management and clinical practices, policies and processes from 1990 to 2000

• Focus to “identify and assess the deficiencies” (1)

• Recommend changes to improve short-comings

1.Executive Summary, Inquiry into KEMH 1990 to 2000, Final Report, Vol.1, November 2001

MethodMethod

• Extended over 18 Months

• Accessed information from 1600 patient files

• Analyzed 605 patient files

• Analyzed ninety-six medico-legal cases

• Compared KEMH clinical performance data with 13 similar Australian services (Consortium)

• Reviewed 293 written submissions

• Interviewed 70 former KEMH patients

• Read 106 transcripts, reports & other documents

• Resource intensive (expensive)

General Observations General Observations regarding Inquiry Reportregarding Inquiry Report

•Very long and difficult to access

•Language of system failure; reality of great detail and “naming names”.

•Was the Inquiry welcomed?

•Readership? Minister/Government? Institutional Governance? Management/Staff? Patients/General Public All of the above?

LimitationsLimitations

•Inquiry Approach negative bias; adversarial lengthy; expensive

•Prone to political influence;

•Focus on high-risk cases;

•Non-representative sampling;

•Limited inter-hospital comparison;

StrengthsStrengths

• Level of detail of review

• Case studies for learning/teaching purposes

• Focus on clinical practice issues not usually talked about: standards of care responsibility and accountability supervision of juniors credentialling and training

• Discussion of management responsibilities for safe care

Findings - StrengthsFindings - Strengths

• Many examples of exemplary care & service

• Concerted effort by some to address or improve long-standing problems

Findings - ManagementFindings - Management

Management failed to:• make & act on important decisions• create an open, transparent, positive

culture• monitor & improve safety & quality• clarify accountability, responsibility &

reporting• ensure staff were properly

trained/supervised• address serious clinical issues

adversely affecting care & clinical outcomes

Findings - Senior Findings - Senior DoctorsDoctors

• Insufficient involvement in complex cases

• Inadequate, delayed or absent decisions

• Inadequate credentialing, appointment, re-appointment, admitting privileges processes

• Inadequate performance management

• Inadequate supervision/training of juniors

• Failed to provide timely, detailed analysis of staffing needs

Findings - Junior DoctorsFindings - Junior Doctors

• Left to do much of the complex work

• Unreasonably burdened with difficult cases

• Inadequately supervised/supported

• Requests for help often delayed or ignored

• Blamed for errors - “sink or swim”

• Inadequate orientation & training

• Supported more by midwives than senior doctors

Findings - Clinical PracticeFindings - Clinical Practice

Ineffective or absent:

• care planning, coordination, documentation

• policies & practices based on best evidence

Poor management of:

• complex & emergency cases

• women needing intensive care services

• incidents & adverse events

Poor clinical & emotional outcomes for women & families

Findings: Clinical Review Findings: Clinical Review & Reporting& Reporting

Inconsistencies in:

• review and report of deaths to the Coroner

• report, review and response to incidents & adverse events

• management of complaints and medico-legal cases

• review & compare clinical performance & respond to performance issues

Findings - Internal Policies Findings - Internal Policies and Processesand Processes

Absent or inadequate:• quality improvement program• incident/adverse event monitoring &

follow-up• complaints & medico-legal case

management• committee functioning & review• policy development, deployment,

review • recruitment, employment,

performance management, training

Findings - Women & Findings - Women & FamiliesFamilies

• Often excluded from decisions about care

• Concerns ignored or overlooked

• Treated poorly as complainants

• Given untimely and inadequate information, particularly when things went wrong

• Rarely involved in policy decisions

Comparison with BristolComparison with Bristol

• Heart surgery on babies in Britain’s Bristol Infirmary from 1988 to 1994

• Deaths following arterial switch operation

• Excessive time take to do procedure

• Concerns raised repeatedly by an anaesthetist

• Senior doctors and chief executive eventually faced prosecution

Common ThemesCommon Themes

In both cases, management’s failed to:• respond to important issues raised

repeatedly • ensure clinicians were properly trained• build a culture of transparency/open

disclosure• establish effective quality systems • give patients & families adequate

information about risks, care & problems with care

• effectively manage complaints/medico-legal cases

Lessons for Institutional Lessons for Institutional Management and Management and

GovernanceGovernance1. Leadership & Culture

2. Accountability & Responsibility

3. Safety & Quality Systems

4. Staff Support & Development

5. Concern for Consumer & Families

System IssuesSystem Issues

Institutional Governance• Role of Board, Management in Patient

Safety• Importance of Benchmarking and

Comparative Data• Importance of Incident Monitoring,

Reporting, Management and Review• Importance of Mortality Review• Importance of Periodic External Review of

Management Policies, Procedures and Practices

SystemSystem Issues

System Governance• Role of Regulatory/Statutory Authorities

Mortality Committees; Coroner

• Role and Function of External Accreditation Standards of practice (incl credentialling)

• Role and Structure of “Special Inquiries”• Importance of Comparative Data

voluntary versus mandatory clinical privilege (Immunity) public disclosure

ConclusionsConclusions

• Inquiry is a landmark in the evolution of health care safety and quality policy and practice in Australian hospitals;

• ACS&QHC Summary and Implications document should be required reading for all hospital managers and Boards

• We should learn from the Inquiry findings and limitations to develop better ways of monitoring and reporting safe patient care environments.